Get Enrollment Form - Retiree - Notebook Lausd

The Enrollment Form - Retiree - Notebook Lausd is an essential document for retirees seeking to continue their health benefits. This guide provides clear, step-by-step instructions to help users effectively complete the form online.

Follow the steps to fill out the Enrollment Form with ease.

1. Press the ‘Get Form’ button to acquire the Enrollment Form and open it in your editor.
2. Begin by entering your employee number, last name, first name, middle initial, address, city, state, zip code, and phone number in the designated fields. Ensure that the information is accurate and up to date.
3. Provide your Social Security number and date of birth. This information is crucial for identification purposes.
4. Indicate your retirement date and select whether you are applying for service retirement or disability retirement.
5. Choose the health plans you wish to enroll in at the time of retirement. This includes options for medical, dental, and vision coverage. Make sure to read the eligibility criteria for each option.
6. Fill out the dependent information section if applicable. Enter the Social Security number, last name, first name, date of birth, relationship, and sex for each dependent. If more space is needed, attach additional pages.
7. Complete the Medicare information section if applicable. This is mandatory for individuals or dependents aged 65 or older. Provide Medicare claim numbers and effective dates for Parts A and B.
8. Sign and date the form to confirm that all information provided is accurate to the best of your knowledge. Your application will not be processed without this signature.
9. Review all sections of the form to ensure everything is completed correctly. Once satisfied, you can save changes, download, print, or share the completed form as needed.

Complete your Enrollment Form online to secure your health benefits without delay.